Blended learning supported by digital technology and competency...

Trujillo Maza et al. International Journal of Educational Technology in HigherEducation (2016) 13:27 DOI 10.1186/s41239-016-0027-9

RESEARCH ARTICLE Open Access

Blended learning supported by digitaltechnology and competency-based medicaleducation: a case study of the socialmedicine course at the Universidad de losAndes, Colombia

Elena María Trujillo Maza1*, María Teresa Gómez Lozano2, Andrés Camilo Cardozo Alarcón3,Lorena Moreno Zuluaga4 and Mariana Gamba Fadul1

* Correspondence:[email protected] of Medicine, Universidad delos Andes, Calle 18 # 2 – 68, edificioQ – 817, Bogotá, ColombiaFull list of author information isavailable at the end of the article

©Lpi

Abstract

Blended courses supported by digital technology (bLearning) and competency-basedmedical education can be found in different university curricular reform initiativesaround the world. Today, it is essential to implement new technologies andteaching methods that are flexible and encourage students to acquire the necessaryprofessional skills.This article describes how using the bLearning format transformed the Social Medicinecourse for second-year medical students at Universidad de los Andes (Colombia),particularly their ability to achieve target competencies. A qualitative case study wascarried out to explore the curriculum structure, training and skills, educational modeland learning environments used during the course. We discuss the methodsused, the results achieved, and the challenges encountered during theimplementation process.Findings show that bLearning both facilitated the transformation of the coursedesign and promoted flexibility and autonomy in students’ learning process.Additionally, the new format facilitated the development of various competenciesincluding: cognitive, technical and procedural, integrative and communicative,reflection, and professional ones.

Keywords: Blended learning, Competency-based medical education, Project-basedlearning, Social medicine

IntroductionBlended Learning (bLearning) supported by digital technology and competence-based

medical education (CBME) are transforming professional education in the 21st

century. Several publications discuss the possibilities and challenges associated with

this trend. They show the usefulness of bLearning in making learning more meaningful

both at the personal level and at the social level (Hew & Cheung, 2014; Prat-

Corominas, Palés-Argullós, Nolla-Domejó, Oriol-Bosch, & Gual, 2010).

2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 Internationalicense (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,rovided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, andndicate if changes were made.

http://crossmark.crossref.org/dialog/?doi=10.1186/s41239-016-0027-9&domain=pdfmailto:[email protected]://creativecommons.org/licenses/by/4.0/

Trujillo Maza et al. International Journal of Educational Technology in Higher Education (2016) 13:27 Page 2 of 13

Information and communication technologies allow for relatively easy access to know-

ledge in a variety of areas outside of educational institutions (Castells, 2006; Martín-Barbero,

2002). For higher education institutions in particular, the use of this modality provides an

opportunity to transform pedagogical approaches, thus allowing students to create know-

ledge in collaboration with others (Hopenhayn, 2003; Márquez & Jiménez-Rodrigo, 2014)

and to understand how to use information in a specific context. Additionally, this creates

the need for more flexible learning environments that allow people to acquire knowledge

anywhere, anytime, and at their own pace. bLearning, understood as a mixture of face-to-

face and distance learning, has become an answer to this need, because it combines and

integrates the best strategies of each modality (Galvis & Pedraza, 2013).

Numerous cases suggest the benefits of the bLearning modality and the possibilities it of-

fers to boost the development of skills in different disciplines. Sánchez (2015) describes vari-

ous cases across disciplines in which students from different areas (communication

sciences, graphic design, public relations and advertising) who were taking part in a bLearn-

ing course were tracked throughout their learning processes. Another study by Aguado,

Arranz, Valera-Rubio, and Marín-Torres (2011) describes a program based on this approach

which was designed for a group of professionals from a company belonging to the electricity

sector.

The CBME approach promotes both individual and collaborative knowledge creation thus

allowing students to integrate information that will be used in different contexts and experi-

ence learning as meaningful. Both of the aforementioned are key aspects of the constructiv-

ist paradigm (Prat-Corominas et al., 2010). In other words, this model promotes situated

and contextualized learning which prepares students for real life issues consequently acquir-

ing the professional skills that are the goal of CBME (Trujillo & Zambrano, 2015). Addition-

ally, CBME assessment seeks a more complete and authentic approach to evaluating the

student’s performance; it applies different strategies and assessment tools that facilitate the

observation of student achievement on the proposed professional competencies (Pinilla-

Roa, 2013).

Although there are several approximations to the implications of CBME, Frank et al.

(2010) summarize the principal ideas. CBME has: 1. a curricular structure focusing on out-

comes, and measureable skills and development of competencies through the use of clear

evaluation criteria; 2. a learner-centered process which places emphasizes on the needs of

society and the student’s context; 3. a concern for individual differences of the learner, espe-

cially allowing the student to learn at his or her own pace, hence fostering an individual

learning process.

With regard to the development of competencies, it has been found that developing com-

petencies is more difficult in completely virtual settings than in blended ones. Through

reading or participating in forums exclusively fewer people can develop skills such as negoti-

ation techniques or leadership proficiencies (Aguado et al., 2011). As a result, bLearning

modalities allow for the combination of online methods with face-to-face learning which

boost the development of target competencies. As is described by Turpo (2012), p. 129, “in

operational terms, bLearning includes online activities in both its instructional design and

in its face-to-face activities both of which are structured pedagogically such that competen-

cies/objectives are achieved” (author translation).

These changes in educational and research perspectives have shown that physicians

trained under the CBME model have performed better in a globalized world (Frank et al.,


2010; Palés-Argullós, Nolla-Domenjó, Oriol-Bosch, & Gual, 2010). Therefore, different re-

sources have been allocated to transform the curriculum designs in medical education.

The purpose of this study was to explore the way in which the transformation of the So-

cial Medicine course to a bLearning modality impacted the achievement of target skills in

second year medicine students from the Universidad de los Andes (Colombia). The peda-

gogical transformation and the course learning outcomes will be described in the next

sections.

The transformation of the social medicine course: bLearning and competence-based

learning

The course considered for this study was mainly organized around lecture classes in

which students were guided through the essential concepts about health, health promo-

tion, disease prevention, and predictors for disease. The revision of the course syllabus

emerged from the instructor’s pedagogical reflection about her conceptions and educa-

tional practices. This reflection, which was both an individual and collaborative process,

was crucial for the improvement of educational practices. The reason for this is that a

reflective practice leads the instructor to transform their daily practices and therefore

modify students’ learning (Gómez, Ternent de Samper, Alba, & Ghitis, 2013).

Initially, we decided to review the course program beginning with the analysis of the

core competencies we planned to foster in the students. The methodology and ap-

proaches to assessment were adjusted in keeping with the curriculum alignment pro-

posed by Biggs (2006). Later on, the virtual and face-to-face settings were decided upon

and a course which promoted autonomy and collaborative work was created. Fourteen

face-to-face sessions that lasted two hours each were designed. The course’s key con-

cepts were addressed through workshops, discussion panels with experts, interventions

in educational institutions and final papers. Throughout the course, ten two-hour vir-

tual sessions were implemented as well. In these virtual sessions, students completed

different tasks that reinforced face-to-face session outcomes. These included videos

and readings from visiting professors and student participation in a Wiki, where they

displayed their learning using the thinking routine connect-expand-challenge on the

reviewed materials (Krechevsky, 2012). It is important to note that students also used

the Wiki to construct their project and to carry out the self and peer evaluation of their

group work.

At a second stage of the implementation, the design was carried out for one semester.

Using different methodological strategies, an evaluation process was conducted. Before

participating, participants signed an informed consent. The information gathered led to

a new adjustment of the program, the face-to-face and online spaces, and also of the

digital platform design. This was done with the objective of improving the course’s

learning atmosphere and, in consequence, the students’ learning processes.

It is important to note that the use of Blackboard®, the virtual platform in which this

course is based, changed significantly. Before the pedagogical transformation, it served

only as a repository for different readings, to publish assignments, show grades to stu-

dents and facilitate email exchange between the instructors and the teaching assistants.

Thanks to the new design, available Web 2.0 tools were put into use, especially Wikis

and teamwork dynamics. This led to better interaction with the available resources and


the creation of collaborative work dynamics among students. Communication between

students and the team of instructors and teacher’s assistants also improved.

Today the course aims at developing four competencies in second-year medicine stu-

dents (Table 1), and this is accomplished through their participation within two specific

projects. In these projects, they have contact with different health problems and risky

scenarios in individual, family and community contexts. The methodology used is

called Problem-Based Learning Organized by Projects (PBL-OP).

The first project consisted in creating an intervention focusing on the promotion of

mental health for students from different programs at the Universidad de los Andes.

The impetus for this particular intervention was based on a study of social determi-

nants of health and issues that had been prioritized by the Dean of Students and the

student body of the university. The second intervention project was based on a case

study of a student with learning disabilities at a public high-school in Bogotá. In this

case, the ecological model was used on the basis of which the students’ health status

could be analyzed. Taking it from there a feasible proposal to both school and families

could be developed to improve the students’ well-being.

Finally, assessment processes revealed what students had learned in the course and per-

mitted us to monitor the achievement of the target competencies. Assessments were con-

ducted individually and collectively both online and face-to-face throughout the project

phase of the course. Each time the students submitted their work, they were provided

with an assessment rubric that included specific scoring criteria based on the learning ob-

jectives (Tables 2 and 3). The use of these assessment tools led to the early detection of

students with low academic performance, which in turn, allowed us to give them timely,

appropriate guidance to help them acquire the competencies proposed for the course.

MethodologyThe objective of this study is to explore the way the transformation of the Social Medi-

cine course using the bLearning modality helped second-year medicine students of

Universidad de los Andes acquire a series of target competencies. A qualitative case

study which explored students’ academic transformation and outcomes was conducted

(Stake, 2007). According to Stake (2007) and Yin (2009), case studies can provide the

researchers with both the uniqueness and complexity of a particular case, thus allowing

them to acknowledge the diverse perspectives of those involved in this transformation

process.

This research was conducted during the first semester of 2015. It drew on three

sources of information. First, the key documents of the course were examined (course

program, final papers and students’ reflections). Second, semi-structured interviews

Table 1 Competencies in the Social Medicine course in the first semester of 2015

1. Acquires basic knowledge related to the concepts of health prevention and health promotion and appliesthem to the project proposals.

2. Understands the models for approaching the health-disease process, such as the social determinants ofhealth and the ecological model, which are generated from the interaction between the individual, the family,the community. Also understands the risk factors and the protective factors present in these processes.

3. Knows and applies basic concepts of qualitative research as well as psychosocial screening tools used in theholistic approach to individuals.

4. Understands the importance of and reflects about the professional values implicit in team work and in healthcare in communities. Actions reflect respect for the others.

Table 2 Assessment rubric for “Health-Promoting University” project

Assessment criteria Percentage Score

5.0 4.0 3.0 2.0 1.0

Describes and analyzes the case-problem using the principles of thesocial determinants of health model.

25 %

Appropriately uses the principles of qualitative research to understandand analyze the problem of the assigned case.

20 %

Formulates a plausible and creative health promotion and diseaseprevention strategy in accordance with the problem of the assigned case.

25 %

Adequately references the sources used in the paper. 15 %

Writing, grammar and spelling fulfill the expectations for academiccompositions at the university level.

15 %


were designed and carried out with two students, two teaching assistants and two in-

structors. Focus groups were conducted with three teaching assistants and two groups

of four students. Finally, to complement the aforementioned data, an online survey was

applied. It was completed by 83 % of the students at the beginning of the semester and

by 40 % at the end of the semester. The information gathered through the document

analysis and the qualitative methods was transcribed and coded using the categories de-

scribed below. The categories were created to analyze the curricular structure, the

training process, the skills acquired by students, the academic model and the learning

environments used in the course.

1. Methodology (pedagogical strategies used during the course)

2. Modality (different components that are part of the bLearning modality)

3. Assessment (different tests and evaluation processes conducted during the course)

4. Competencies (components of the CBME)

5. Instructor’s role (as a learning guide or as a content provider during the course)

6. Student’s role (the students’ involvement in the development of the course as an

active learner and builder of knowledge or as a passive learner and recipient of

knowledge)

To analyze the data, the software ATLAS.ti® Version 7 was used. To analyze and in-

terpret online survey responses, Microsoft Excel® (2013) was used. The data from the

different sources was triangulated.

Table 3 Assessment rubric “Learning Disabilities” project

Assessment criteria Percentage Score

5.0 4.0 3.0 2.0 1.0

Describes the problem appropriately, justifies its relevance andsets clear goals.

20 %

Formulates a methodology that is coherent with the case anddescribes it adequately.

20 %

Analyzes the case using the principles of the ecological model,integrating the information gathered during the process withthe bibliographic sources.

20 %

Proposes health promotion and disease prevention strategiesspecifically aimed at their assigned case.

20 %

Adequately references the sources used in the paper. 10 %

Writing, grammar and spelling fulfill the expectations for academiccompositions at the university level.

10 %


Results and discussionIn this section, we present the results by category and discuss them in the same order.

To address the research objective, we place particular emphasis on findings related to

assessment and competencies.

Category 1: course methodology

The course methodology allowed students to become the protagonists of their own

learning process and to fulfill the course objectives through the following projects:

“Health Promoting University” and “Case Study of a Child with Learning Disabilities”.

Participants highlighted that they became engaged in these projects, not only for aca-

demic reasons, but also because it contributed to their professional development. One

student commented:

Aside from the obvious, like the readings and videos, I believe the strategy that best

describes the way I was able to internalize the concepts was the chance to apply them

to real life. It’s no use reading about the meaning of health determinants, what they

are and what they are for, if I can’t feel them more tangibly (Student Interview).

On the other hand, the instructor and the teaching assistants discovered that the im-

plementation of this methodology required them to form teams of students. This meant

organizing the teams responsibly by creating team rules, norms for communication and

group work, and expectations about solidarity and cooperative leadership so that stu-

dents could achieve the activities. These characteristics constitute important skills that

medicine students must develop within the CBME model (Frank et al., 2010; Prat-

Corominas et al., 2010).

Category 2: instructional modality

The use of the bLearning modality helped students to reach their learning objectives.

As stated by Galvis and Pedraza (2013), this approach created a more flexible learning

environment in which students could learn in their own time and space, and also at

their own pace.

Students and teacher’s assistants highlight that the online classwork prepared them

for the face-to-face sessions and was complementary to their learning process. Among

the most useful strategies were collaborative reading and the accessibility of the con-

tents online, both of which made it possible for students to better comprehend key

concepts required to develop the course projects:

Through the use of the online resources, I could understand the idea of a Health

Promoting University. I was able to comprehend the importance of these dynamics in

health promotion strategies […] I understood how these initiatives are crucial in the

field of Medicine […] (Student focus group).

[Students] worked collaboratively online […] and the face-to-face sessions became so

important that it is worth it to attend class (Teacher’s assistant interview).


Data also showed that students experienced difficulties when they were not accus-

tomed to the bLearning modality and its requirements. Another finding related to the

use of bLearning is that it improved students’ teamwork skills as is shown in the results

of the survey in Figs. 1 and 2.

Category 3: assessment

The assessment process in the course was aligned with the objectives and the method-

ology (Biggs, 2006). Learning outcomes were determined from student projects and for-

mative assessment was used to help students recognize their strengths and weaknesses

as they developed course competencies.

I think it’s really positive that the students receive feedback more quickly, especially

about smaller tasks, because they can monitor their performance and don’t have to

wait until the end of the course to know what they are doing right or wrong (Teacher’s

assistant interview).

The written exam […] is a completely different kind of evaluation from any other one

used in the University because it’s based on cases […] so I had to actually apply the

concepts that I have been learning (Student interview).

There are many cases in which students do not identify with this methodology. The same

thing happens with this new type of evaluation because during students’ academic career,

they are mostly evaluated using content-based exams. This is the reason why some students

and teaching-assistants in this focus group consider non-traditional evaluations to be a

weakness, because without traditional content-based exams they feel unable to realize in

Fig. 1 Students’ perception of collaborative learning/group work at the end of the course

Fig. 2 Students’ perception of collaborative learning at the end of the course


how far they meet the course objectives with respect to acquired knowledge. Nevertheless,

the results of the evaluation processes show clearly that they did allow the students to

achieve the target competencies, as shown in the final grades of the course (Fig. 3).

Category 4: competencies

The purpose of transforming the approach to this course was to shift from a content-based

learning method to a CBME. This change garnered a positive response from the actors in-

volved in this project as the following quote indicates:

[…] It’s true learning because it transcends theory. This experience made me more

human. I managed to feel empathy for the girl, to put myself in her shoes and thanks

to this, I gained an understanding that surpasses classes, readings and words

(Student’s reflection).

Through a PBL-OP approach, students developed different CBME core skills in-

cluding cognitive, technical, integrative, contextual, relational, affective and moral

competencies (Epstein & Hundert, 2002). One reflection recounts that:

I understood that there’s a direct link between the patient’s context and his or her

health. This relationship is multifactorial and is constituted by many variables like

resources, finances, occupation, psychosocial and cultural environments, to mention a

few (Student’s reflection).

Furthermore, the data analysis shows that other competencies developed involve stu-

dents’ ability to reflect on their task, their role as physicians and their autonomy.

It’s the first time that they as medical students are faced with a person’s problem and

that they have to solve it through teamwork. So, they develop new problem-solving

Fig. 3 Students’ final course grades


abilities and new skills to research what they need to do so (Teacher’s assistants focus

group).

The learning skills achieved in the projects can be observed in Fig. 4. Finally, the

survey showed that most of the students believe they acquired the skills proposed

in the course syllabus. This perception corresponds with the results of the course

evaluation (see Fig. 5).

Category 5: the professor’s role

The findings show that for the different parties involved in the Social Medicine course,

teachers have a special role that allows them to guide students’ learning processes:

[…] I think it is respectful to have a role in which I can support them, guide them,

and motivate them to learn. The teacher’s assistants have also assumed this role

(Professor interview).

Likewise, teaching-assistants played an important role in the development of the

course projects due to their support of students in face-to-face and online learning

spaces:

[…] After applying this methodology, now [the course] is more dynamic, though it

requires more time because teaching-assistants support the students as they develop

their projects and we answer questions in a more consistently and closer way

(Teacher’s assistants focus group).

In the end, many of the students claim that they would like to continue to having this

is the type of professor in their medical training. One commented that:

I feel very comfortable because this [course] gives us more independence to manage

methodologies and time as we do the projects. Since the class focuses on projects, the

Fig. 4 Achievement of competencies evaluated in each project

Fig. 5 Average scores assigned by students at the end of the course evaluating the acquisition ofcompetencies on a Likert scale where 1 means “nothing” and 5 means “a lot”



projects are our ideas and they are not really influenced by the professor […] (Student

focus group).

Category 6: student’s role

It is possible to confirm that the students’ roles have changed with the transformation

of the course. The course transformed from one with passive students who were recipi-

ents of knowledge, as is typical of traditional teaching models, to one with active stu-

dents who constructed their own knowledge. This is due to the course’s orientation

towards the CBME model, the PBL-OP methodology and the use of the bLearning mo-

dality (Fig. 6):

I learned a lot from online learning, much more than from face-to-face, because I

was completely responsible for my learning process and for being conscious of the

objectives of each virtual session (Student’s interview).

ConclusionsBased on the results described in the previous section, it is our aim to highlight how

the new course design has allowed students to develop the target competencies.

These outcomes derive from the alignment between the objectives, the methodology

and the assessment (Biggs, 2006). The objectives focus on: the competencies and the

PBL-OP methodology combined with the bLearning modality. This particular com-

bination of methodologies conceives of the student as the protagonist and the in-

structor as a guiding figure who participates actively in the construction of learning.

The student’s main role is achieved due to the fact that the PBL-OP approach

promoted meaningful learning experiences and also encouraged students to find

the course contents meaningful for them (Frank et al., 2010; Prat-Corominas et al.,

2010). By the same token, the combination of this methodology with bLearning

made it easier for the instructors to monitor their students’ learning processes.

Fig. 6 Student perception of autonomy development at the end of the course


This allowed them to observe their strengths and weaknesses in the development

of the course competencies.

The instructor’s role in the design of learning environments is just as important

as the students’ role, as many researchers have suggested (Galvis & Pedraza, 2013;

Hew & Cheung, 2014). Considering the new role of the professor in this approach

is paramount for the articulation of flexible learning spaces with different resources

in both the online and face-to-face settings. Besides this, the instructor facilitates

feedback opportunities, which allow students to achieve the target competencies.

We can observe that this model promotes learning for many students whereas

for others, it is still a difficult model to understand and cope with. Some students

feel more comfortable when they are placed in a passive role. They express a

tension between having the instructor as a guide and their wish for the professor

to continue being a transmitter of knowledge. However, this changes as the

students make their learning visible in the completion of course projects.

In sum, this article describes the opportunities, difficulties, and challenges faced

during the curricular implementation of this course. This CBME course using

bLearning and PBL-OP shows that it is possible to combine the approaches

approximations in different disciplines and learning environments as is shown in

the Colombian foreign language learning experience (González-Moreno, 2011;

Mendieta-Aguilar, 2012). In similar fashion, these outcomes also arise in the imple-

mentation of the Management and Public Administration curriculum as shown by

Márquez and Jiménez-Rodrigo (2014).

Finally, the authors of this article believe that these transformations can be achieved

in different types of curricula. Yet, whatever the discipline, it is not only a transform-

ation to the methodology and modality that is required: the permanent reflection of the

instructor about student learning and educational processes is also fundamental.

Author details1School of Medicine, Universidad de los Andes, Calle 18 # 2 – 68, edificio Q – 817, Bogotá, Colombia. 2School ofEducation, Universidad de los Andes, Calle 18 # 2 – 68, edificio Ñb – 101, Bogotá, Colombia. 3Graduate ResearchAssistant, Universidad de los Andes, Calle 18 # 2 – 68, edificio Q - 817, Bogotá, Colombia. 4Center for Innovation andTechnology in Education (Conecta-TE), Universidad de los Andes, Calle 18 # 2 – 68, edificio Pedro Navas, 1 piso,Bogotá, Colombia.

Received: 1 December 2015 Accepted: 8 April 2016

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https://earlychildhooddevelopment.ca/sites/default/files/u1933/session_2h_handouts.pdfhttps://earlychildhooddevelopment.ca/sites/default/files/u1933/session_2h_handouts.pdfhttp://dx.doi.org/10.14483/udistrital.jour.calj.2012.2.a10http://dx.doi.org/10.4321/s1575-18132010000300002http://dx.doi.org/10.4321/s1575-18132010000400002http://dx.doi.org/10.4321/s1575-18132010000400002http://dx.doi.org/10.4135/9781483348858.n8

AbstractIntroductionThe transformation of the social medicine course: bLearning and competence-based learning

MethodologyResults and discussionCategory 1: course methodologyCategory 2: instructional modalityCategory 3: assessmentCategory 4: competenciesCategory 5: the professor’s roleCategory 6: student’s role

ConclusionsAuthor detailsReferences

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